Synopsis On 09July 1996 the Canadian ferry CAMILLE MARCOUX was docked at the ferry wharf at Baie-Comeau, Quebec. During the final stages of loading vehicles on the parking deck, a tow truck towing a cement mixer moved onto the apron leading to the parking deck. After parking the cement mixer, the tow truck backed up toward the loading ramp and struck a pedestrian who was walking on the loading ramp apron, with his back to the tow truck. The Board determined that the pedestrian was struck by the tow truck as he was walking on the loading ramp apron, with his back to the truck, because access was not closed to vehicles while pedestrians were walking on the loading ramp, and because a signaller was not positioned at the rear of the tow truck to guide the driver while he was backing up. The driver did not see the pedestrian walking on the apron, the tow truck was not equipped with an automatic backing-up alarm and the pedestrian did not look out for the tow truck as he left the vessel. 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel 1.1.2 Description of the Loading Ramp 1.1.3 Description of the Tow Truck 1.2 History of the Occurrence 1.3 Injuries to Persons 1.4 Damages 1.5 Certification 1.5.1 Vessel 1.5.2 Personnel 1.6 History of Personnel and Individuals Involved 1.6.1 Master 1.6.2 First Mate 1.6.3 Boatswain 1.6.4 Victim 1.6.5 Tow Truck Driver 1.6.6 Loading Ramp Attendant 1.7 Weather and Tidal Information 1.8 Socit des traversiers du Qubec 1.9 Ferry Schedule 1.10 Traffic on the Loading Ramp 1.11 Loading Ramp Management Instructions 1.12 Operating Instructions for the Parking Deck 1.13 Backing-up Alarms for Heavy Trucks 2.1 Access to the Loading Ramp 2.2 Vehicle Traffic 2.3 Assistance for Drivers of Heavy Trucks 2.4 Impact of Ferry Schedule on Safety 2.5 Hazard Warning 2.6 Backing-up Alarm 2.7 Written Safety Management Instructions 3.1 Findings 3.2 Causes 4.1 Action Taken 4.1.1 Coroner's Recommendations 4.1.2 Pedestrian Boarding Ramp 4.1.3 Audible Alarm Appendix A - Sketch of the Occurrence Area Appendix B - Sketch of the Loading Ramp Appendix C - Photographs Appendix D - Glossary Appendix A - Sketch of the Occurrence Area Appendix B - Sketch of the Loading Ramp Appendix C - Photographs Appendix D - Glossary 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The CAMILLE MARCOUX is a roll-on/roll-off ferry; the parking deck is equipped with an after ramp. At the bow it is equipped with a visor that pivots upward, and a bow ramp that pivots downward to facilitate vehicle loading and unloading. The navigation bridge is forward of the accommodation and above the parking deck. The vessel has a capacity of 600 passengers and 126 vehicles. 1.1.2 Description of the Loading Ramp The Baie-Comeau terminal services one route to Matane, Quebec, on the south shore of the St.Lawrence River. The terminal has a ramp for loading and unloading vehicles which includes a pedestrian lane. The loading ramp is hinged at the shore end to allow adjustment for the height of the tide. The pedestrian lane is roped off along the edge of the ramp and is covered with a non-slip mat. At the vessel end, the loading ramp extends into a hinged apron that rests on the bow ramp of the vessel. The apron is narrower than the loading ramp, and this section does not have a separate pedestrian lane. 1.1.3 Description of the Tow Truck The tow truck has tandem rear axles and is capable of towing heavy vehicles. It has a net weight of 12,610 kg. The field of view through the rear window of the tow truck cab is restricted by the hoisting apparatus. The tow truck is fitted with side mirrors for viewing the side rear. On 09July 1996, while the CAMILLE MARCOUX was docking at the Baie-Comeau marine terminal, the vessel's bow visor was raised and the bow ramp lowered. At 1915 docking was completed and the loading ramp apron was lowered onto the vessel's ramp.[3] The pedestrians aboard started across the loading ramp, followed by the 115 vehicles on board the ferry. Vehicle loading began at approximately 1930. When loading was almost completed, the persons in charge of traffic on the ferry guided a tow truck, which was towing a cement mixer, toward the parking areas available in the forward section of the ferry. The former owner of the cement mixer, and his uncle, followed the cement mixer on foot and went aboard. The former owner wanted to assist the tow truck driver. The cement mixer was parked along the port side bulwark. At about 1950 two blasts of the ferry's whistle were sounded to signal that the vessel would be departing in about ten minutes. The first mate asked the former owner of the cement mixer to hurry and unhook the cement mixer and leave the parking deck. A brief but animated discussion followed between the former owner and the first mate. The tow truck, which was ahead of the cement mixer, was caught between it and the vehicles parked on the parking deck. The tow truck driver obeyed the signals of the boatswain assigned to guide him. After several manoeuvres, the tow truck was clear and it proceeded toward the ramp of the ferry. The signaller walked to the front and on the left of the tow truck. When the tow truck backed onto the loading ramp apron, the driver and boatswain lost sight of the former owner and his uncle, who were walking back toward the loading ramp. The first mate asked the former owner to move aside but the latter continued to walk in the middle of the apron while his uncle was a few steps behind him, on the port side of the vessel ramp. The loading ramp attendant, who saw the tow truck backing up toward the former owner, shouted and waved his arms to signal to the former owner to move away; even the former owner's son, who was at the edge of the loading ramp, signalled to him to clear the way for the tow truck. However, the former owner appeared not to realize that the tow truck was coming closer to him. At about 1955 the tow truck struck the former owner in the back, knocked him down on the apron, and the right rear wheels rolled over his body. When the driver heard shouting, he stopped the tow truck on the loading ramp, with the rear wheels on the ramp and the front wheels on the apron. The victim was lying on the loading ramp apron between the front and rear wheels of the tow truck. The master was informed, and he used the ship's public address system to ask whether there was a doctor among the passengers who could offer assistance to the victim. A nurse went to the scene of the accident and immediately administered first aid. At 2001 the crew called for an ambulance. On arriving on board, the local police administered cardiopulmonary resuscitation to the victim, but to no avail. The victim remained motionless on the loading ramp apron. The ambulance attendants arrived on the scene at 2025, and the victim was transported to the local hospital, where a physician pronounced him dead. According to eyewitnesses, the tow truck backed onto the apron at a speed exceeding the 5km/h limit indicated on the traffic sign posted at the ferry exit. 1.3 Injuries to Persons The chief coroner's office took charge of the victim's body to conduct an autopsy. According to the forensic report by the ministre de la Scurit publique du Qubec, death was caused by multiple trauma due to crushing. 1.4 Damages The vessel sustained no damage. Neither the loading ramp nor the tow truck were damaged in the accident. 1.5 Certification 1.5.1 Vessel The CAMILLE MARCOUX is crewed, equipped and operated in accordance with existing regulations. 1.5.2 Personnel The personnel on the parking deck of the ferry consists of eight crew members: two officers, one boatswain and five deck-hands. These crew members were certificated for the positions they occupied and for the service for which the vessel is used. 1.6 History of Personnel and Individuals Involved 1.6.1 Master The master had 46 years' sailing experience, including 26 years as master. Since 1983, he was the master of the CAMILLE MARCOUX, as a permanent employee of the Socit des traversiers du Qubec (STQ). 1.6.2 First Mate The mate had 16 years' sailing experience, including 3 years as first mate. He had held a permanent position as first mate on board the CAMILLE MARCOUX since 27June 1995. 1.6.3 Boatswain The boatswain had 29 years' experience at sea, including 18 as boatswain. He had held a permanent position as boatswain on board the CAMILLE MARCOUX since 1979. 1.6.4 Victim The man who lost his life had a permanent position in a factory in Baie-Comeau, and was also the owner of the cement mixer company Bton D'Astous. He had sold his fleet of vehicles and, at the time of the accident, he was delivering the cement mixer to its new owner on the south shore. 1.6.5 Tow Truck Driver The tow truck driver had 25 years' experience as a mechanic, and he had been driving a tow truck for 6 years. 1.6.6 Loading Ramp Attendant The loading ramp attendant had 21 years' experience and had taken a loading ramp operator course in 1994. 1.7 Weather and Tidal Information The weather conditions recorded by the crew agreed with the observations of other witnesses. The weather was clear, with northeast winds at five knots and a temperature of 11C. It had rained earlier in the evening of July 9, but the loading ramp was dry at the time of the accident. Mean low water was around 1555. The tide was rising at the time of the occurrence, and the loading ramp sloped slightly in relation to the vessel parking deck. 1.8 Socit des traversiers du Qubec The STQ, a Crown corporation established 04June 1971, operates a fleet of 13 vessels, 11 of which ply 8 routes servicing 15 terminals along both shores of the St.Lawrence River. 1.9 Ferry Schedule During the summer months, the schedule published by the STQ for Tuesday crossings between Matane and Baie-Comeau was as follows: The schedule does not state either the arrival time or the minimum stopover time in Baie-Comeau. The ports are approximately 33 nautical miles apart, and the vessel's service speed is 15 knots. Thus, the time required for the crossing, without allowing for weather and currents, is about 2hours and 15minutes. In this instance, the ferry left Matane at 1701 and arrived at Baie-Comeau at 1915. During the stopover at Baie-Comeau, 226 passengers and 115 vehicles disembarked before 180 passengers and 103 vehicles boarded for the return crossing to Matane. As no reservation had been made for transporting the cement mixer, the stowage plan had to be modified at the last minute, which may have occasioned an unforeseen delay. 1.10 Traffic on the Loading Ramp At the time of the accident the ferry was not equipped with a gangway ladder for pedestrians. They and the vehicles used the same access to the vessel, the loading ramp and the vessel's bow ramp, which leads into the accommodation. Thus, according to the ferry wharf user guide published by Public Works and Government Services Canada for passenger embarkation and disembarkation attendants, at the beginning of each stopover the loading ramp is reserved for pedestrians disembarking from and boarding the ferry, and the unloading and loading of the vehicles is done afterward. Red and green traffic lights mounted on the left side of the loading ramp indicate when vehicles are allowed to proceed onto the loading ramp. Passengers are not allowed on the parking deck during the crossing. The terminals are designed differently at each port. In the case of the CAMILLE MARCOUX, which transits essentially between the ports of Godbout, Matane and Baie-Comeau, docking is done as follows in the latter two ports: The ferry is always docked bow-in at Baie-Comeau and stern-in at Matane. Thus, the vehicles drive forward to board via the bow ramp at the Baie-Comeau terminal, and they drive forward off the ferry via the after ramp at the Matane terminal. In this instance, the tow truck was indeed driven forward when loading the cement mixer, but it was driven in reverse when leaving because space on the parking deck was limited, since the loading of the ferry was almost completed. 1.11 Loading Ramp Management Instructions The operation of the loading ramp is described in a guide entitled Guide d'utilisation de l'embarcadre routier de Baie-Comeau, prepared for loading ramp attendants by Public Works and Government Services Canada in February 1992. Paragraph 2.6 of this guide states that, as regards traffic control, no vehicle will be allowed on the ramp when pedestrians are using the ramp. For several years, in talks with federal authorities, the STQ had promoted the installation of a pedestrian ramp. In his report on this accident, the coroner recommended that the relevant authorities, namely the federal and provincial departments of transport, jointly build separate access ramps for pedestrians and vehicles, in order to give pedestrians access to the vessel's deck without having to walk on the ramp used by vehicles, as in this instance. Since then, the operators of the Matane-North Shore route acknowledged the coroner's recommendations, and stated that they have already implemented them in part. At the Matane and the Baie-Comeau terminals, work has begun on a ramp to provide pedestrians with a direct access to the vessel that is separate from the vehicle ramp. 1.12 Operating Instructions for the Parking Deck The crew members responsible for loading and unloading the CAMILLE MARCOUX meet a few times a year to discuss changes to shipboard operations. Arrangements made at these meetings are verbal. The STQ also provides training sessions on the signals that the parking deck crew are required to use when stowing vehicles. The crew members assigned to loading and unloading guide the vehicles only on the parking deck. In practice, only one signaller is assigned to guide car drivers, while drivers of heavy trucks and semi-trailers are assisted by two signallers. At the time of the occurrence, only one signaller was used for the manoeuvres, when the tow truck was leaving, because it was on the parking deck not to be stowed, but only to bring the cement mixer on board. 1.13 Backing-up Alarms for Heavy Trucks In Quebec, backing-up alarms are not mandatory for all heavy trucks. Also, the Quebec Highway Safety Code does not contain any regulations respecting backing-up alarms. To date, only the Commission de la sant et de la scurit du travail (CSST) has adopted regulations requiring vehicles weighing 2,500kg or more, operating on construction sites, to be equipped with such a device. The coroner who conducted the inquiry into the occurrence on board the CAMILLE MARCOUX filed his report and recommendations in March 1997. Once again, in one of his recommendations, the coroner acknowledges the importance of backing-up alarms for heavy vehicles. That recommendation, made to the Socit de l'assurance automobile du Qubec (SAAQ), is for vehicles over 5,500kg to be equipped with automatic backing-up horns.